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The Honolulu Advertiser

Posted on: Monday, March 22, 2004

HMSA's cholesterol mistake

By Frank Singer, M.D.
Chief of endocrinology and metabolism at Straub Clinic and Hospital

The Hawai'i Medical Service Association is the dominant private healthcare insurer in Hawai'i, representing six out of seven people with private health insurance in the state.

HMSA has been sending letters to its members recently who are being treated for high cholesterol, stating that the more potent "statin" drugs will no longer be preferred, recommending a switch to the generic, lovastatin, in order to save money.

In one letter that a patient of mine showed me, it was stated that local practicing physicians and pharmacists on HMSA's Pharmacy and Therapeutics Advisory Committee have claimed, for example, that lovastatin is equally effective to Lipitor, a potent branded statin that is currently the most frequently prescribed member of this cholesterol-lowering group.

In a head-to-head study of various statin medications, it was found that 10 mg of Lipitor lowers the "bad" (LDL) cholesterol better than 40 mg of lovastatin, but when the dose of lovastatin was raised to 80 mg, Lipitor was not significantly better. Unfortunately, there is evidence that, as the dose of lovastatin is raised, the risk for side effects also increases.

It is interesting that HMSA does not choose to employ advising physicians who have specialty training in the field of cholesterol metabolism, that is, endocrinologists. I recently attended a meeting of the Hawai'i chapter of the American Association of Clinical Endocrinologists in which the membership, without dissent, expressed worry about the consequences of HMSA's new policy.

Experts in the field of cholesterol management have published guidelines to help physicians create treatment goals for their patients with high cholesterol. These goals are periodically revised and, historically, have always been revised downward to levels lower than previously were thought to be appropriate. One of the big challenges to physicians has been to try to overcome both their own and patients' fears about the potential side effects of medications used at higher doses. HMSA's new policy is likely to cause greater difficulties in achieving cholesterol-lowering goals.

In reality, the evidence continues to accumulate that the less potent statin drugs are also less effective in preventing heart attacks and the need for coronary artery interventions. This was first observed several years ago in a study using a high dose of Lipitor in patients with known coronary artery disease, comparing outcomes to patients given their usual care, which included lower doses of statins. The latest study, which will appear soon in the New England Journal of Medicine, shows that lowering LDL cholesterol into the 60s is superior to lowering LDL cholesterol into the 90s in terms of preventing heart attack.

The problem that we see here with HMSA's insurance policy regarding the statins is only an example of a larger issue that patients and their physicians face trying to maintain the highest quality of healthcare in Hawai'i. HMSA makes rules that presumably are well-intentioned, but are also sometimes ill-advised. If HMSA makes a mistake with a policy that shapes healthcare in a bad way, to whom are they accountable?

HMSA is involved in trying to shape the behavior of both patients and physicians. HMSA has created standards that it claims represent quality of care and applies them to physicians, with the consequence that physicians who conform to their standards are paid more for their services. Ironically, in some cases, the physician does not even know that this is going on. But how does HMSA know that the standards that it has created are correct? Again, there is no oversight of the policies that HMSA creates.

Ultimately, HMSA has set itself up as if it were the appropriate representative of the Hawai'i people's health when, in fact, it is a healthcare insurer with an agenda that includes self-service. Its power appears to be unchecked since outside of Kaiser, it enjoys a virtual monopoly in the area of private healthcare insurance. To whom does HMSA answer?